CurrentUnitedHealthcarePolicy CSOH2026D0055.C

Medical Benefit Drug Policy — Cinqair (reslizumab), Fasenra (benralizumab), & Nucala (mepolizumab) (Ohio)

Defines medical benefit coverage and clinical references for reslizumab (Cinqair), benralizumab (Fasenra), and mepolizumab (Nucala) administered SC or IV for members in Ohio; self-administered Fasenra and Nucala are covered under the pharmacy benefit. Applies to UnitedHealthcare plans governed by Ohio requirements.

Policy Summary

PayerUnitedHealthcare

PolicyMedical Benefit Drug Policy — Cinqair, Fasenra, & Nucala (Ohio)

Policy CodePolicy CSOH2026D0055.C

Change TypeRoutine review — no content changes

Effective DateMar 1, 2026

Next Review Date

Key ActionRefer to Ohio Department of Medicaid Unified Preferred Drug List Criteria and OAC 5160-1-01 to determine medical necessity for Cinqair, Fasenra, and Nucala prior authorization requests.

SourceLink

POLICY UPDATE CHANGES

03/01/2026 routine review; no content changes and previous policy version CSOH2025D0055.B archived.

3drug products referenced

Ohio-onlyapplicability

Self-adminFasenra and Nucala benefit channel

OAC 5160-1-01medical necessity reference

Coverage and Medical Necessity Criteria

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Initial and ongoing medical necessity

Covered when ALL of the following are met according to referenced Ohio Medicaid criteria

Referenced criteria: Use Ohio Department of Medicaid Unified Preferred Drug List Criteria and OAC 5160-1-01 to determine medical necessity for Cinqair, Fasenra, and Nucala

This policy delegates specific clinical criteria to Ohio Medicaid UPL criteria

Self-administration of Fasenra and Nucala is managed under the pharmacy benefit rather than the medical benefit.

Requests for services that are stated as unproven or that exceed a coverage or quantity limit will be evaluated for medical necessity and may be considered not medically necessary under Ohio Administrative Code 5160-1-01 if the applicable criteria are not met.

Initial Therapy Requirements

Initial therapy

Initial coverage is determined by Ohio Medicaid UPL criteria and OAC 5160-1-01.

Reference-driven: Initial therapy coverage requires meeting Ohio Department of Medicaid Unified Preferred Drug List Criteria as referenced by this policy

Detailed criteria are in the referenced Ohio Medicaid documents

Step	Description	Reference
1
Clinical coverage criteria per the Ohio Department of Medicaid Unified Preferred Drug List may include step requirements; consult the referenced Ohio Medicaid UPL Criteria for the specific step-therapy requirements for Cinqair, Fasenra, and Nucala.
Ohio Department of Medicaid Unified Preferred Drug List Criteria (see policy reference)

Provider Requirements, Authorization, and Denial Triggers

Prior Authorization

Prior Authorization Required

Cinqair, Fasenra, and Nucala require medical necessity review and prior authorization when billed to the medical benefit. Authorization decisions will use the Ohio Department of Medicaid Unified Preferred Drug List clinical coverage criteria and may reference InterQual criteria as applicable.

Drugs affected: Cinqair (reslizumab); Fasenra (benralizumab); Nucala (mepolizumab).
Fasenra and Nucala self-administration are obtained under the pharmacy benefit; medical-benefit requests for these products still require review.
Prior authorization must document that Ohio Department of Medicaid Unified Preferred Drug List clinical criteria are met.

Documentation Required

Provider Actions / Documentation

Providers must confirm applicable federal, state (Ohio Administrative Code), and contractual requirements before submitting requests. UnitedHealthcare policies are interpretive aids; in a conflict, federal, state (OAC), or contractual requirements govern.

Check member’s benefit plan for pharmacy vs medical benefit applicability prior to submission.
Provide clinical documentation demonstrating fulfillment of Ohio Department of Medicaid Unified Preferred Drug List criteria.
Be prepared to supply prior authorization history, dosing, route (SC vs IV), and evidence of prior therapies where required.

Denial Risk

Denial Triggers

Requests that do not meet the referenced Ohio Administrative Code or the Ohio Department of Medicaid Unified Preferred Drug List clinical coverage criteria may be denied.

Denial triggers include lack of documentation meeting Unified Preferred Drug List criteria, treatments billed to the incorrect benefit (pharmacy vs medical), or requests for unproven indications.
Quantity or coverage-limit exceptions must reference OAC 5160-1-01 and the member’s contract; absent supporting documentation, authorization may be denied.

Site of Care and Benefit Channel

Billing Rule

Site-of-care and benefit channel — document administration setting

Products administered by a clinician via subcutaneous or intravenous routes are covered under the medical benefit when appropriately administered; confirm administration site (infusion center, office, or home) and note that self-administration of Fasenra and Nucala is obtained under the pharmacy benefit.

Document the administration setting (infusion center, office, or home) on the claim and in authorization requests.
Do not bill the medical benefit for self-administered Fasenra or Nucala — those are handled through the pharmacy benefit.

Definitions and Background

This policy addresses specialty biologic therapies — Cinqair (reslizumab), Fasenra (benralizumab), and Nucala (mepolizumab) — when administered by the subcutaneous (SC) or intravenous (IV) route for members in Ohio. Coverage determinations for these products rely on the Ohio Department of Medicaid Unified Preferred Drug List Criteria; where requests are for self-administered Fasenra or Nucala, those products are obtained under the pharmacy benefit. This Medical Benefit Drug Policy applies only to the state of Ohio and references OAC 5160-1-01 for evaluation of services described as unproven or subject to limits.

inv-09: Fasenra and Nucala (self-administration under pharmacy benefit)

Designated self-administered productsFasenra (benralizumab) and Nucala (mepolizumab) are designated for self-administration.

Benefit channel assignmentSelf-administration of Fasenra and Nucala is obtained under the pharmacy benefit rather than the medical benefit.

Other related productsCinqair (reslizumab) is referenced in the policy but not designated for self-administration under the pharmacy benefit.

Clinical coverage referenceMedical necessity clinical coverage criteria for these agents are determined by the Ohio Department of Medicaid Unified Preferred Drug List Criteria.

ScopeApplies to the specified specialty biologic products for members in Ohio as described in the policy.